A Dead End: Deep Endometriosis and Silent Kidney Death

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is Deep Endometriosis and Silent Kidney Death?
• What are the Risks of Deep Endometriosis and Silent Kidney Death?
• Video Transcript

Video Description

Ureteric endometriosis is associated with deep infiltrating endometriosis and can lead to obstructive hydroureteronephrosis. Given the chronic nature and lack of symptoms, diagnosis of hydronephrosis is often delayed, which can lead to silent kidney death. Presence of deep infiltrating endometriosis warrants routine investigation of kidney function and structure with creatinine and upper urinary tract imaging in order to avoid this catastrophic outcome. This video demonstrates a surgical case of severe, late onset bilateral obstructive nephropathy secondary to ureteric endometriosis that required left nephrectomy. The surgical approach is reviewed including the approach to salvage of the solitary ureter and kidney with extensive endometriosis disease burden. In this case, ureterolysis is utilised in order to normalise the anatomy of the solitary right ureter and save solitary right kidney function, while achieving optimal endometriosis resection.

Presented By

Affiliations

The Ottawa Hospital; Minimally Invasive Gynecology

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What is Deep Endometriosis and Silent Kidney Death?

Deep endometriosis is a severe form of endometriosis characterized by endometrial-like tissue infiltrating more than 5 millimeters below the peritoneal surface, often affecting organs outside the uterus, such as the bladder, intestines, and ureters. This invasive nature can lead to significant complications, including “silent kidney death” or silent loss of kidney function.

• Definition: Deep endometriosis can involve multiple pelvic organs and cause extensive scarring, inflammation, and adhesions, resulting in chronic pain, menstrual irregularities, and potential infertility.

• Silent Kidney Death: When deep endometriosis infiltrates the ureters (the tubes connecting the kidneys to the bladder), it can obstruct urine flow. This obstruction may occur gradually, often going unnoticed until it results in severe kidney damage or even loss of kidney function. Because symptoms are often subtle, this process is termed “silent.”

• Detection and Diagnosis: Diagnosis of deep endometriosis typically involves imaging techniques such as ultrasound or MRI to assess the extent of invasion. Silent kidney death may be detected through imaging studies showing hydronephrosis (swelling of the kidneys) or through lab tests revealing compromised kidney function.

• Management: Treatment options may include hormonal therapy to suppress endometrial tissue growth, surgical intervention to remove lesions and relieve obstructions, and regular monitoring to prevent further damage. Early intervention is crucial to avoid irreversible kidney damage.

In cases of deep endometriosis, timely detection and treatment are essential to protect organ function and improve patient quality of life.

What are the Risks of Deep Endometriosis and Silent Kidney Death? 

Video Transcript: Deep Endometriosis and Silent Kidney Death

The title of this video presentation is A Dead End, Deep Endometriosis and Silent Kidney Death. We have no conflicts of interest or financial gains to disclose from this presentation. We will aim to review the following objectives. First, to recognise when and how to evaluate the kidneys in cases of deep endometriosis. Second, we’ll review a case of deep endometriosis with associated kidney death and illustrate a surgical approach to deep ureteric endometriosis management.

Ureteric endometriosis represents less than 1% of all endometriosis. However, it is significantly more prevalent in cases of deep infiltrating endometriosis. Ureteric endometriosis may be intrinsic or, more commonly, extrinsic, causing ureteric compression and associated hydronephrosis. This leads to a blown out, dead kidney that may warrant nephrectomy. Diagnosis is often delayed due to late symptom onset and the risk of silent kidney death is up to 50%.

The presence of deep infiltrating endometriosis warrants careful evaluation of kidney function and structure, with measurement of creatinine and upper urinary tract imaging. Our patient is a 37-year-old female with a six-year history of endometriosis, who was referred to complex benign gynaecology. On initial consult, creatinine was elevated and she was in hypertensive emergency. She was admitted for further work-up and management of her hypertensive crisis.

MRI revealed significant bilateral hydronephrosis, with a blown out, non-functional left kidney, causing significant secondary hypertension. MRI also demonstrated bilateral deep endometriosis causing bilateral ureteric impingement. Operative management was recommended. Our goals included complete resection of endometriosis burden, restoration of right ureter patency and left kidney nephrectomy, as recommended by urology.

This was all planned with the underlying goal of fertility preservation and protection of the remaining sole right ureter and kidney. Our approach began with nephrectomy performed by urology. On entry, the kidney was dilated and cystic. After the dilated ureter was laparoscopically stapled, the associated ovarian vessels were clipped at the level of the pelvic brim. Second, to access the deep pelvic structures, the left ovary, containing several large endometriomas, was mobilised and removed.

This was achieved with dissection of the retroperitoneal space of the left pelvic side wall. The previously clipped ovarian vessels were used to guide dissection of the left ovary and fallopian tube. The left ovary and tube were further dissected from overlying bowel adhesions, leading to incidental rupture and spillage of classic chocolate cyst material identifying endometrioma. After the left ovary and tube were removed, the deep pelvis could be accessed.

The right ovary was temporarily suspended to improve access to the right pelvic side wall and deep pelvic spaces. To further delineate anatomy, the bilateral perirectal spaces were dissected in order to address the rectal nodule and improve careful dissection around the right ureteric nodule. Here, the right ureter is seen clearly distinct from the rectum.

Dissection of the perirectal spaces ensures complete resection of the dense fibrosis between the rectum and the posterior aspect of the uterus in order to prevent recurrence of disease infiltrating the remaining right ureter. We then shifted our focus to preservation of the remaining right ureter. To obtain patency of the right ureter, the dilated right ureter was identified transperitoneally. Ureterolysis was then performed by opening the overlying peritoneum.

Surgical techniques of traction, countertraction, push and spread and blunt dissection were utilised to carefully dissect the ureter. Care was taken to maintain ureteric vasculature in order to prevent stricture. The right paravesical space was opened and dissected, demonstrating the insertion of the right ureter into the uterovesicle junction of the bladder. Ureteric vasculature is maintained using cold scissor dissection in close proximity to the ureter.

A ureteric catheter was easily passed through the ureter to confirm patency and aid dissection. Due to the extent of parametrial disease, uterine artery ligation was performed. The right uterine artery was identified in the paravesical space, with the right ureter passing inferiorly. Here, the right uterine artery coming off the side wall is travelling into the nodule, which is encasing the right ureter. The right uterine artery is then clipped and transected in order to aid in resection of parametrial disease.

After uterine artery ligation, the nodule can be carefully dissected away from the path of the ureter in order to assist in normalising anatomy. Resection and ureterolysis was performed in this case because the ureter maintained its patency. Following resection of the right ureteric nodule, the anatomy of the ureter was normalised. Similarly, left uterine artery ligation was also performed in order to completely resect left parametrial disease.

The left uterine artery was identified in the left parametrial space closely associated with the remnant right ureter. At the end of the procedure, a rectal insufflation test confirms no rectal injury. Ureteric catheter was removed. The patient had a right nephrostomy tube that was remained in situ until follow-up with urology. In this case, ureterolysis was performed to salvage the solitary right kidney and ureter, in addition to optimal resection of endometriosis, in order to prevent recurrence of disease.

Thereby maintaining patency and function of her remaining right kidney. Ureterolysis and nodule resection, as done in this video, is one option for treatment of ureteric disease. Invasive disease causing loss of patency may be better treated with ureteric resection and reanastomosis. The method of reanastomosis is best determined based on location of disease and extent of invasion. In summary, presence of deep infiltrating endometriosis should prompt regular assessment of kidney function and structure with creatinine and imaging.

Surgical intervention with resection of endometriosis should be considered early in order to prevent advanced disease and silent kidney death.